Trigeminal Neuralgia and bell's palsy

Trigeminal Neuralgia and bell's palsy

1. Trigeminal Neuralgia And Bells Palsy 10/8/2020 Sujata Devkota 1

2. Trigeminal nerve -5 th cranial nerve -most complex nerve -responsible for sensation of face, motor function like chewing ,biting etc Sujata Devkota 2 10/8/2020

3. Trigeminal Nerve Sujata Devkota 3 10/8/2020

4. Definition Neuralgia - severe pain coming from a nerve. “Sudden usually unilateral severe, brief, stabbing, recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve. -The International association for study of pain(IASP). Sujata Devkota 4 10/8/2020

5. Cont’d… It is associated with involuntary movement of facial muscles so there is sudden closing of eye or twitching of mouth so it was formerly called Tics Douloureux (painful twitch). Most painful condition known to human . It is uncommon. Prevalence rate is 155 cases per million. Age: common from 50-69 years Female affected twice often as male. Sujata Devkota 5 10/8/2020

6. Etiology 1.Exact cause is unknown. 2.Degenerative or viral origin suspected. 3.Intrinsic lesions 4.Extrinsic lesions Sujata Devkota 6 10/8/2020

7. Cont’d… Risk factors Nerve compression Kidney insufficency Herpes virus infection, syphilis Infection of teeth and jaw Trauma on facial nerve Chemical irritation Sujata Devkota 7 10/8/2020

8. Clinical Manifestation Sujata Devkota 8 10/8/2020

9. Clinical Manifestation cont’d… Abrupt onset, extensive episodic pain(30-60sec) Pain rarely relieved by analgesics. Trigger points and attacks Aggravating factors Note: Individual attacks usually affect one side of the face at a time, lasting from s everal seconds to a few minutes and repeat up to hundreds of times throughout the day Sujata Devkota 9 10/8/2020

10. Clinical Manifestation cont’d… The attacks feel like stabbing electric shocks, burning, pressing, crushing, exploding or shooting pain that becomes intractable. Pain from trigeminal neuralgia is so intense that patient ponders suicide. So,called “THE SUICIDAL DISEASE” Sujata Devkota 10 10/8/2020

11. Diagnostic evaluation History taking Neurological examination Blood test - Renal function and glucose level. Angiography, CT scan, and MRI can identify a causative lesion. Sujata Devkota 11 10/8/2020

12. Management 1.Medical Management Anticonvulsant drug-carbamazepine, gabapentin Analgesic: Phenytoin (assess LFT) Skeletal muscle relaxant- Baclofen OTC analgesics: Aspirin,ibuprofen Sujata Devkota 12 10/8/2020

13. 2.Surgical management A.Rhizotomy ( rhizolysis ) To cut anterior/posterior spinal nerve root Nerve fibers are damaged to block pain. Always causes some degree of sensory loss and facial numbness. Several forms of rhizotomy are available to treat trigeminal neuralgia. Sujata Devkota 13 10/8/2020

14. Cont’d… Some are: Radiofrequency thermal lesioning Microvascular decompression(MVD) Balloon compression Glycerol injections Stereotactic radiosurgery Sujata Devkota 14 10/8/2020

15. Radiofrequency thermal lesioning ("RF Ablation“) -Most often performed on an outpatient basis.  -Use heat generated by radio waves to target nerves - Thus, temporarily blocks the pain signal. - Needle is inserted to the opening of trigeminal nerve. -Nerve area is heated with a frequency of 500khz -can repeat until preservation of touch. -Symptoms may reoccur 3-4 years in half of patient. Sujata Devkota 15 10/8/2020

16. Microvascular decompression (MVD) - Most invasive of all. -Offers lowest probability that pain will return. -Reoccurrence may be with in 12-15 years. -Done under general anesthesia in in-patient basis. - A small incision made through mastoid bone. -Surgeon moves away the vessel that compress the nerve. Then place a soft cushion between vessel and nerve. Sujata Devkota 16 10/8/2020

17. Microvascular decompression (MVD) Sujata Devkota 17 10/8/2020

18. Balloon compression   - Procedure selectively affect the trigeminal ganglion -under general anaesthesia . -A balloon is inflated inside the skull to compress the ganglion and help with pain relief. - Pain relief usually lasts one to two years . Sujata Devkota 18 10/8/2020

19. Balloon compression Sujata Devkota 19 10/8/2020

20. Glycerol injection -An outpatient procedure -Needle passed through the opening in the base of skull where mandibular nerve exists. IV glycerol is injected into the area of mandibular nerve . Thus numbs the nerve and reduce pain. May reoccu r with in 1-2 years . Sujata Devkota 20 10/8/2020

21. Glycerol injection Sujata Devkota 21 10/8/2020

22. Stereotactic radiosurgery (Gamma knife) - Least invasive of all -Uses computer imaging to direct focused beam of radiation Gamma knife delivers precise, controlled beams of radiation to the site where trigeminal nerve exit at brain stem.  Pain relief occurs only after several weeks . Pain may reoccur within 3 years. Sujata Devkota 22 10/8/2020

23. Stereotactic radiosurgery (Gamma knife) Sujata Devkota 23 10/8/2020

24. Surgical management cont’d… B. Neurectomy : -Also called partial nerve section -Involves cutting part of nerve. -May be performed near the entrance point of the nerve at the brain stem Sujata Devkota 24 10/8/2020

25. Nursing Management Assessment: History: pain, duration, severity, aggravating factors Nutrition status and hydration Anxiety and depression Sleep problems Social interaction Coping skills Sujata Devkota 25 10/8/2020

26. Nursing Management cont’d… Nursing diagnosis: Chronic pain related to compression of nerve. Imbalance nutrition, less than body requirements related to pain during eating. Disturbed sensory perception related to disease condition. Sujata Devkota 26 10/8/2020

27. Nursing diagnosis cont’d… Powerlessness related to lack of control over painful episodes. Knowledge deficit related to unknown disease condition. Sujata Devkota 27 10/8/2020

28. Nursing Management cont’d… Expected outcomes: Patient will experience pain relief. Nutritional status will be maintained. Sensory perception will be improved. Control over painful episodes will be improved Knowledge level will be upgraded . Sujata Devkota 28 10/8/2020

29. Nursing Management cont’d… Intervention 1.Relieve pain -Review triggering factors -develop individualized coping. - Take medicine regularly. -Alternative methods of communication Sujata Devkota 29 10/8/2020

30. Nursing Management cont’d… 2.Maintain adequate nutrition - Chew on unaffected side -Observe for any difficulty in eating -Eat at room temperature. - Appropriate diet. - Frequent meals -Nutritional supplements if needed. Sujata Devkota 30 10/8/2020

31. Nursing Management cont’d… 3.Enhancing protection - Assess corneal reflex -Check eyes every 3-4 times -Do not rub eyes. -Instill artificial tears every 4 hourly. Sujata Devkota 31 10/8/2020

32. Nursing Management cont’d… 4.Increasing control - Relaxation techniques. -Involve in decision making. -Involve in ADL during pain free situation. -Interact with other clients with same problem . Sujata Devkota 32 10/8/2020

33. Nursing Management cont’d… Postoperative care: Neurological assessment Assess eyes for irritation Artificial tears to prevent dryness. Sujata Devkota 33 10/8/2020

34. Complications Anorexia and weight loss Dehydration Anxiety, fear Depression, social isolation, and suicidal ideation in extreme cases. Sujata Devkota 34 10/8/2020

35. Bell’s palsy Sujata Devkota 35 10/8/2020

36. Introduction Defined as unilateral inflammation of seventh cranial nerve which results in weakness and paralysis of facial muscles on the affected side. A type of acute peripheral paralysis Can affect anyone at any age and sex Sujata Devkota 36 10/8/2020

37. Epidemiology Most common cause of acute unilateral facial paralysis- 60 to 75% Annual incidence -approximately 15-30 cases/1 lakhs Incidence increases with age Pregnancy -during 3 rd trimester, increase with pre eclampsia Recurrence rate -4-14% Sujata Devkota 37 10/8/2020

38. Epidemiology cont’d… Diabetes -29% chance Right side is affected most-65% Bilateral -23% mostly with GBS, neurofibroma Both sex are affected equally More frequent at younger age. Sujata Devkota 38 10/8/2020

39. Etiology The exact cause is unknown . Possible causes include autoimmune diseases, vascular ischemia. Tumor ,trauma on facial nerve. Viral diseases like herpes zoster, simplex Gullian barre syndrome. Sujata Devkota 39 10/8/2020

40. Bell’s palsy Sujata Devkota 40 10/8/2020

41. Clinical features Most experience a viral infection 1-2 weeks before onset of symptoms. Facial paralysis: acute onset, weakness all over face Mouth: diminished taste, drooling ,lagging angle of mouth Sujata Devkota 41 10/8/2020

42. Clinical features cont’d… Eye: decreased blink reflex, decreased or increased lacrimation , inability to close eyes, painful eye sensation, photophobia, drooping of eyelid. Hyperacusis on the affected side. Sujata Devkota 42 10/8/2020

43. Diagnostic procedure History taking- previous illness, onset of paralysis Physical examination: evaluation of 7 th cranial nerve function, corneal sensation Neurological assessment: complete examination of all of the cranial nerves and cerebellar testing Sujata Devkota 43 10/8/2020

44. Diagnostic procedure cont’d… Blood test for sugar and kidney function test. Lumbar puncture(LP) for CSF analysis. CT scan and MRI Electromyography and nerve conduction velocities Sujata Devkota 44 10/8/2020

45. Medical management Main goal is to maintain muscle tone of the face. Spontaneous recovery occurs with in 3-5 weeks in most patients. Sujata Devkota 45 10/8/2020

46. Medical management cont’d… Steroid therapy- Prednisolone -early administration has good prognosis Analgesics-NSAIDS for facial pain Hot/warm compression in the involved side. Proper eye care. Sujata Devkota 46 10/8/2020

47. Medical management cont’d… Physiotherapy –wrinkling forehead, squeeze eyes, purse lip, blowing out cheeks, whistling, etc Electrical stimulation in face. Surgical exploration in case of tumor. Biofeedback techniques is effective Sujata Devkota 47 10/8/2020

48. Surgical management Only indicated when other measures fail. Anastomosis of CN VII to CNXI or CNXII Closure of eyelid ( Tarsorrhaphy ). Sujata Devkota 48 10/8/2020

49. Nursing management 1)Assessment: Medical history: risk factors Physical examination: pain , disturbed body image, corneal integrity, nutritional status, patient’s knowledge level   Sujata Devkota 49 10/8/2020

50. Nursing management cont’d… 2)Diagnosis Pain on the affected side related to disease condition. Disturbed visual perception related to impaired corneal integrity. Disturbed body image altered facial expression secondary to bell’s palsy. Sujata Devkota 50 10/8/2020

51. Nursing management cont’d… Knowledge deficit related to newly diagnosed disease. Risk for impaired nutritional status related to difficulty in chewing secondary to bell’s palsy. Sujata Devkota 51 10/8/2020

52. Nursing management cont’d… 3)Expected outcome Patient will experience pain relief. Corneal integrity will be maintained. Patient will demonstrate positiveness towards body image. Patients level of understanding will be improved. Patient’s nutritional status will be maintained. Sujata Devkota 52 10/8/2020

53. Nursing management cont’d… 4.Intervention: Relieving pain -medications, moist heat, facial massage Protecting corneal integrity- artificial tears and ointments, eye patches , sunglasses, frequent inspection Sujata Devkota 53 10/8/2020

54. Nursing management cont’d… Enhance body image -explore feelings, use of mirror Diet and nutrition -chewing on unaffected side, balance diet, frequent mouth care Patient education -use of sunglass, eye shield at night, medications, warm face. Sujata Devkota 54 10/8/2020

55. Complication Excessive dryness may lead to infections ,ulcers and even blindness. Synkinesis Sujata Devkota 55 10/8/2020

56. Synkinesis Sujata Devkota 56 10/8/2020

57. References Black, J.M., and Hawks, J.H.,(2009), Medical Surgical Nursing, volume 2, pp 1886-1890 BT, Basavanthappa ., (2003) Medical Surgical Nursing, (1 st ed.),pp 586-590 Smeltzer , S.C., Bare, B.G.,(1996)Textbook of medical surgical nursing,(8 th ed.), pp 1815-1818 Baniya , T.U., and Aryal , Kalpana.P .,(2013) Neuroscience Nursing (1 st ed.),pp 188-194 Sharma , M., Paudel , K., and Gautam , R.,(2074), Essential text book of medical and surgical nursing, (2nd ed.), Samiksha publication, pp 367-370 Sujata Devkota 57 10/8/2020

58. Cont’d… Suzanne, SC., Brenda, B.G., Janice, H.L. and Kerry, HC., (1973), Brunner and Suddharth’s Textbook of Medical Surgical Nursing, (12 th ed.),volume II, pp 1521-1522,1522-1523 Topic bell’s palsy retrieved on 22 nd 2020 https://www.healthline.com/health/bells-palsy Topic bell’s palsy management retrieved on 22 nd 2020 https://www.nursingpath.in/2018/05/bells-palsy-management-and-nursing-care.html Sujata Devkota 58 10/8/2020